Technically Speaking: When It Comes to MenACWY, Join the “We Never Guess! We Look It Up” Club

As a third grader, I belonged to the “We Never Guess! We Look It Up” club. We were committed to using our new classroom encyclopedias (paper versions of Wikipedia) to get the facts. When, as a pediatric resident, I was asked about the immunization schedule, I did not have to look it up. I had it completely memorized — there were only three childhood vaccines. Now, when I need an answer to a complex immunization schedule question, I turn to the technically sophisticated clinical decision support in my electronic health record, my state’s immunization information system, or a nurse.

Where do nurses in the “We Never Guess” club find answers? Many are devotees of the Vaccine Education Center at CHOP, Immunize.org, and The Vaccine Handbook (also available for Android or iOS).

MenACWY increases membership in the “We Never Guess” club

One of the vaccines that by necessity increases the “We Never Guess” club membership is meningococcal vaccine, specifically MenACWY. N. meningitidis causes a particularly destructive form of meningitis that often leaves patients with long-term neurologic conditions, including deafness, weakness or paralysis, fluid on the brain, or developmental delay. Even worse, it can cause an invasive syndrome that, even with prompt medical care, causes 15% to 20% death rates in affected adolescents and adults. This is one of the infections that emergency medicine physicians most fear overlooking and most fear finding.

While you probably know that all adolescents should have a 2-dose MenACWY vaccine series starting at 11–12 years of age with the booster at age 16, test your knowledge beyond these basics with the questions below. You can use the following weblinks if you want to join the “We Never Guess” club:

• A Look at Each Vaccine: Meningococcal Vaccine, Vaccine Education Center
• Meningococcal ACWY Vaccine Recommendations by Age and Risk Factor, Immunization Action Coalition (IAC)
• Ask the Experts: Meningococcal ACWY, IAC
• Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States, 2021, Centers for Disease Control and Prevention (CDC)
• Catch-up immunization schedule for persons aged 4 months–18 years who start late or who are more than 1 month behind, United States, 2021, CDC

QUESTION #1: In addition to the routine recommendation for MenACWY vaccination of adolescents, there are risk-based recommendations for vaccination of some adults. Which of the following adults should receive MenACWY? (Choose all that apply)

1. People with chronic heart, lung (including asthma), liver, or renal disease
2. People living with HIV
3. People who smoke cigarettes
4. People with cerebrospinal fluid leak or cochlear implant
5. Military recruits

Q1 Answer: The adults described in answers B and E should receive MenACWY. People living with HIV and military recruits should receive MenACWY. See this CDC webpage for more details.

Pneumococcal, but not meningococcal vaccination, is recommended for people with chronic heart, lung, liver, or renal disease; those who smoke cigarettes; and those who have a cerebrospinal fluid leak or cochlear implants. For more on pneumococcal vaccination recommendations, please see this CDC webpage.

QUESTION #2: The following students have no underlying health conditions. Which students should receive MenACWY at today’s appointment? (Choose all that apply)

1. A 16-year-old who received dose one at age 15 years of age, 11 weeks ago
2. A 16-year-old who received dose one at age 16 years of age, 11 weeks ago
3. An 18-year-old who received dose one at 12 years of age
4. An 18-year-old who received dose one at 17 years of age
5. A 19-year-old, first-year college student living in a residence hall, who received dose one at 12 years of age

Q2 Answer: A, C, and E need a MenACWY today.

1. They had dose one when younger than 16 years and more than 8 weeks have passed since dose one, so dose two would be appropriate to administer at today’s appointment.
2. They had dose one between 16 and 18 years of age, so no additional dose is recommended at this time.
3. They had dose one when younger than 16 years old and more than 8 weeks have passed since dose one, so dose two would be appropriate to administer at today’s appointment.
4. They had dose one between 16 and 18 years of age, so no additional dose is recommended at this time.
5. A first-year college student living in a residence hall who received a prior dose when younger than 16 years of age needs one more dose that would be appropriate to administer at today’s appointment.

QUESTION #3: Which of these patients should receive MenACWY at an appointment scheduled for today? (Choose all that apply)

1. A 4-year-old child on ravulizumab who received the first dose three months ago
2. A 6-year-old child with sickle cell disease who received their first dose at 24 months of age and a second dose at 3 years of age
3. An 11-month-old child with HIV who received the first dose at 9 months of age
4. A 17-year-old is traveling to Senegal (an endemic area) for a return visit. Because of previous travel, he received a dose at 9 years of age and another dose at 12 years of age

Q3 Answer: The children described in answers A and D should receive MenACWY today.

1. Children with anatomic or functional asplenia (including sickle cell disease), HIV infection, persistent complement component deficiency, or receiving treatment with a complement inhibitor (e.g., eculizumab, ravulizumab) who start the MenACWY series at 24 months of age or older need a 2-dose series separated by at least 8 weeks. As such, this child would be recommended to receive dose 2 today.
2. This child has completed the primary series. As such, they do not need a dose today.
3. A child with one of the relevant conditions who starts the MenACWY series between 7 and 23 months of age requires two doses of an age-appropriate version separated by at least 12 weeks with dose 2 given after age 12 months. This child is not only too young to complete the primary series today, but the requisite 12 weeks between doses have not passed.
4. For travelers to endemic areas, if primary vaccination is completed at age 7 years or older, a booster dose should be administered every 5 years thereafter as long as the risk remains.

If you answered the three questions correctly, congratulations! If you looked it up, you are now a member of the “We Never Guess” club.

Tips for keeping patients up to date on MenACWY

Because MenACWY is underutilized, it is important to build systems that get patients protected against this life-altering infection. Try these mechanisms for improving your vaccine coverage rates:

1. Send reminder/recall messages to 16-year-old patients who need their routine booster dose.
2. Run a computer audit twice a year to see the dates of birth and vaccination status for children with relevant chronic illnesses (e.g., HIV infection, sickle cell disease, complement deficiency).

In addition to daily attention in your patient flow, this periodic, focused approach to catch-up helps identify patients who “slipped through the cracks.” For more on this topic, please see Give2MenACWY.org.

When in doubt, if the patient before you might need this life-saving vaccine, never guess!

Resource alert!

For an attractive and interactive web-based educational module on meningitis, check out the “Comprehensive Vaccine Education Program—From Training to Practice” on the Pediatric Infectious Disease Society or Society for Healthcare Epidemiology of America websites.